Professor of Politics at MIT, with a focus on African politics and development

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Global Public Health

Sometimes it’s easier to assume that everything is worse in Zimbabwe. A failing kleptocracy, with a president who makes everyone’s short-list of despicable tyrants, Zim always provides ample ammunition for arguments about the superiority of democratic governance for human development.

And yet, the government has had a fairly successful AIDS levy, which the UN reports has helped to close some of the funding gap associated with declining donor support and increased needs. The levy is a 3 percent tax on income, and with some improved political and economic stability in the past year, this is generating several million dollars in income, perhaps about $25 million in 2011.

Generally, I am not one for ear-marked taxes, but in certain cases, such as war and national disasters, the notion of a general solidarity fund is a quite reasonable way to raise revenues. In the case of AIDS, not only does it provide a justification for an extra burden, but it can help to de-stigmatize the disease by making its eradication a national project. To be certain, there have been reports that AIDS funding from donors and from the tax have not all made their way to the people who need treatment or related services. But along these lines, I must say that when I was in Zimbabwe in November 2010, I visited several observed pretty well functioning government clinics.

Of course, my point is not that the general state of affairs in Zimbabwe is much rosier than what we generally hear (see, for example, my review of Godwin’s The Fear), but that good ideas sometimes come from unlikely places; and that one of the reasons that awful regimes don’t collapse as quickly as we think they should is because they sometimes make and implement decent policies.

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AIDS Study Marks Prevention Breakthrough With Antiretroviral Drugs – WSJ.com. This is very exciting news — for a long time, AIDS activists made the claim that offering treatment to people who are HIV-positive was a good strategy for prevention, because without access to treatment, why would anyone get tested? And if you didn’t know your HIV status, you were much less likely to practice safe sex, etc. While this was and is plausible, I’ve never seen this hypothesis tested.

However, the recent medical study demonstrates conclusively, what medical professionals have been thinking/hoping for some time now — that ARVs reduce infectiousness. In the study cited, it reduced transmission among heterosexual couples by 96 percent! It’s not a vaccine, but it certainly implies that treatment will be critical for prevention. When world leaders get together for the high level UN meeting on AIDS in early June, no one will be able to credibly propose switching AIDS-related budgets away from treatment in favor of prevention. Perhaps this link helps to explain why we are beginning to see infection rates fall in several African countries — as treatment access has greatly expanded in recent years.

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The UNAIDS/IAS workshop concluded yesterday. The most interesting aspect of the day’s session was the consideration of the “global governance” of HIV, which is the configuration of international institutions and actors that try to shape policies, services, behaviors, etc. relevant to the control of the epidemic. The speakers were right to point out some concerns about the problem of large institutions not being able to react with the speed necessary for some types of problems, and for what may seem an unbalanced distribution of authority (still dominated by Northern rich countries, as population and target problems are weighted toward the global South.) To be certain, in an increasingly integrated world, we need to think more about what are the right institutions for addressing truly global problems, rather than thinking about them as problems facing an amalgamation of states.

But I still think it’s worth reflecting more on the enormous successes of global governance organizations in responding to and coordinating responses to this pandemic. Activists can, of course, claim that more should have been done. To think that the rich countries were going to support millions of people on life-saving pharmaceutical treatment in Africa and elsewhere while in many cases (well, really just the U.S.), our own domestic politics does not provide much health care to our own citizens… well, that’s a remarkable story.

Am here at the Tokyo airport, and for the most part, all seems pretty normal here — except for the closure of moving walkways, owing to power cuts associated with the fallout of last month’s natural disasters.

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Amidst the disaster in Japan, what looks a lot like war in Libya, other developments in the Middle East, and so on, “World TB day,” didn’t get much attention today. Even the WHO’s home page top story concerns the efforts to address the damage from the March 11 natural disasters. And of course, that makes a lot of sense given the crisis and desperation of the situation. But it also reminds me of the longstanding challenge of addressing global health threats like TB: it is rare that any single news event will capture the public imagination and elicit a wide response. Rather, as was the case with HIV/AIDS, attention must be created through steady activism and pressure. However, particularly with relatively slow moving epidemics, that momentum often doesn’t build until the human tolls are staggering, and we find ourselves looking back and saying, “if only…” At the moment, I can’t help but find myself concerned about the stream of reports about drug resistant tuberculosis. Intrinsically bad, MDR and XDR (extremely drug resistant) strains exacerbate the severity of HIV epidemics, especially in high-burden countries, where there is substantial co-infection such as in South Africa.

Reuters reports that the WHO estimates that 2 million people will contact some form of MDR TB by 2015 (Reuters), and not surprisingly, the spread continues in places where there is a lack of diagnostic and treatment infrastructure… which in turn is likely to lead to the development of increased drug resistance.

TB is an “old” disease, and has never garnered the activist energy that helped propel HIV/AIDS onto the global agenda. It nicely rode the coattails of such activism – regard the Global Fund for HIV, TB and Malaria… But given my sense of some global fatigue with spending on the AIDS pandemic, TB advocates may need to really launch their own heroic campaign to support the goal of universal detection and treatment of MDR-TB.